What is the best approach to manage a 98-year-old female patient with multiple chronic conditions, including hypoxemia, severe protein-calorie malnutrition, azotemia, pressure injuries, debility, and generalized weakness?

Management of a 98-Year-Old with Multimorbidity: A Patient-Centered Approach Prioritizing Quality of Life and Mortality Reduction

The current management plan is appropriate and should continue with its patient-centered focus on quality of life, comfort, and mortality reduction rather than aggressive disease-specific interventions, given this patient's advanced age, severe frailty, and limited life expectancy. 1

Core Management Framework

Prioritize Patient-Centered Outcomes Over Disease-Specific Targets

For this 98-year-old with multimorbidity, shift away from single-disease guideline adherence toward outcomes that matter most: comfort, function, and quality of remaining life. 1 The American Geriatrics Society explicitly states that CPG-based care may be "cumulatively impractical, irrelevant, or even harmful" for older adults with multimorbidity. 1

• Discontinue or deprescribe medications unlikely to provide benefit within her limited life expectancy (likely <1 year given 9% weight loss in 25 days, severe malnutrition, and multiple organ system failures). 1
• Specifically reconsider: raloxifene (osteoporosis prevention requires years to benefit), aggressive BP targets with triple antihypertensive therapy (may worsen orthostasis and falls), and apixaban (bleeding risk may outweigh stroke prevention at this frailty level). 1
• The mirtazapine 7.5 mg at bedtime is an excellent evidence-based choice as it addresses multiple priority outcomes simultaneously: appetite stimulation, sleep improvement, and potentially reduces nighttime calling-out behavior. [@current plan@]

Address Severe Malnutrition as the Primary Mortality Driver

Severe protein-calorie malnutrition with 9% weight loss over 25 days and prealbumin of 8 mg/dL represents a critical, life-threatening condition that supersedes other chronic disease management priorities. 2, 3, 4

• Malnutrition directly increases pressure injury development and impairs healing—this patient's multiple wounds will not improve without nutritional correction. 2, 3, 4
• The current approach of supplements plus mirtazapine is appropriate, but consider adding high-calorie, high-protein oral nutritional supplements at specific intervals (e.g., 30-60 minutes before meals to avoid displacing food intake). 3, 4
• Weekly weights are insufficient—weigh every 3 days to detect continued decline earlier and adjust interventions. 3
• The thyroid panel reorder is appropriate as hypothyroidism can contribute to weight loss and should be corrected if present. [@current plan@]

Implement Coordinated Interdisciplinary Care

This patient requires an effective interdisciplinary healthcare team with a primary coordinator to avoid fragmented, disease-specific care from multiple specialists. 1

• Designate one primary clinician to coordinate all care decisions and communicate with the patient about priorities, avoiding the "prescribing cascade" where side effects are treated as new conditions. 1
• Engage pharmacy for comprehensive medication review to identify drug-drug interactions, particularly given the combination of mirtazapine, trazodone (serotonin interaction risk), fesoterodine (anticholinergic burden), and anticoagulation. 1, 5
• Physical and occupational therapy should focus on comfort positioning and caregiver training rather than aggressive strengthening, given her severe debility and poor prognosis. 1

Specific Clinical Priorities

Hypoxemia Management: Pragmatic Approach

Accept intermittent SpO₂ in the high 80s to low 90s rather than forcing continuous oxygen use that the patient repeatedly refuses. 1

• The patient is not in respiratory distress and denies shortness of breath—forcing oxygen via nasal cannula that she removes creates unnecessary agitation and staff burden without clear mortality benefit at this stage. 1
• Document shared decision-making that comfort takes precedence over oxygen saturation targets. 1
• Continue monitoring for acute changes suggesting pneumonia or heart failure, but avoid aggressive interventions. [@current plan@]

Pressure Injury and Skin Tear Management

Current wound care protocols are appropriate, but recognize that healing is unlikely without nutritional improvement. 2, 3, 4

• Nutritional status is the strongest modifiable predictor of pressure injury healing—malnutrition increases pressure injury incidence with an odds ratio of 3.66. 4
• Continue q2h repositioning, moisture barriers, and protective dressings as currently ordered. [@current plan@]
• Avoid aggressive debridement given anticoagulation and poor healing capacity. [@current plan@]

Behavioral Management: Nighttime Calling Out

The mirtazapine may address this issue through its sedating and anxiolytic effects—reassess in 1-2 weeks. [@current plan@]

• Avoid adding benzodiazepines, which pose particularly high risks in elderly patients including falls, cognitive worsening, and paradoxical agitation. 5
• Ensure the calling out is not due to pain, urinary retention, or fecal impaction before attributing it to baseline confusion. [@current plan@]
• Consider whether the patient is expressing existential distress or fear of dying alone—palliative care consultation may be appropriate. 1

Azotemia and Renal Function

The BUN elevation (60) with normal creatinine (0.99) suggests prerenal azotemia from dehydration and catabolism, not acute kidney injury. [6, @current plan@]

• Encourage oral fluids but do not force aggressive hydration that may worsen comfort or cause aspiration. [@current plan@]
• The CKD stage 3a is chronic and stable—avoid nephrotoxic medications but do not pursue aggressive renal protection strategies. [@current plan@]

Medication Reconciliation Priorities

High-Priority Deprescribing Candidates

Review the following medications for discontinuation based on limited life expectancy and harm-benefit ratio: 1, 5

• Raloxifene: Requires years to reduce fracture risk; discontinue. 1
• Lisinopril, amlodipine, AND candesartan: Triple antihypertensive therapy is excessive given orthostatic hypotension risk, azotemia, and frailty—taper to single agent (e.g., keep lisinopril for cardiac benefit, discontinue others). 1
• Fesoterodine: Anticholinergic burden worsens cognition and may contribute to confusion—consider discontinuation if urge incontinence is manageable with scheduled toileting. 5
• Propranolol ER: May worsen fatigue and contribute to falls—reassess need for rate control in paroxysmal atrial fibrillation. 1

Medications to Continue

• Apixaban: Continue for now given atrial fibrillation, but reassess if falls increase or bleeding occurs. [@current plan@]
• Mirtazapine: Excellent choice; continue and monitor response. [@current plan@]
• Acetaminophen: Appropriate for pain management; avoid NSAIDs given anticoagulation. [@current plan@]

Goals of Care Discussion

Initiate or revisit goals of care conversation with the patient (if cognitively able) and family regarding priorities for remaining life. 1

• Clarify whether the focus is comfort-oriented care versus life-prolonging interventions (e.g., hospitalization for acute illness, CPR, feeding tube if oral intake ceases). 1
• Document advance directives and ensure all staff are aware of the care plan. 1
• Consider palliative care or hospice consultation given severe malnutrition, multiple organ system involvement, and functional decline. 1

Common Pitfalls to Avoid

• Do not pursue aggressive disease-specific targets (e.g., HbA1c <7%, BP <130/80) that increase treatment burden without improving quality of life at this stage. 1
• Avoid the "prescribing cascade" where medication side effects are treated with additional medications. 1
• Do not add benzodiazepines for agitation or sleep—they worsen falls and cognition in elderly patients. 5
• Recognize that treatments improving one outcome (e.g., survival) may worsen another (e.g., function)—prioritize function and comfort. 1